Nightingale's Environmental Theory

Florence Nightingale, often considered the first nurse theorist, defined nursing almost 150 years ago as

"the act of utilizing the environment of the patient to assist him in his recovery" (Nightingale,

1860/1969). She linked health with five environmental factors: (1) pure or fresh air, (2) pure water, (3)

efficient drainage, (4) cleanliness, and (5) light, especially direct sunlight. Deficiencies in these five

factors produced lack of health or illness.

These environmental factors attain significance when one considers that sanitation conditions in the
hospitals of the mid-1800s were extremely poor and that women working in the hospitals were often
unreliable, uneducated, and incompetent to care for the ill. In addition to those factors, Nightingale also
stressed the importance of keeping the client warm, maintaining a noise-free environment, and
attending
to the client's diet in terms of assessing intake, timeliness of the food, and its effect on the person.

Nightingale set the stage for further work in the development of nursing theories. Her general concepts
about ventilation, cleanliness, quiet, warmth, and diet remain integral parts of nursing and health care
today.

Peplau's Interpersonal Relations Model

Hildegard Peplau, a psychiatric nurse, introduced her interpersonal concepts in 1952. Central to Peplau's

theory is the use of a therapeutic relationship between the nurse and the client.

Nurses enter into a personal relationship with an individual when a need is present. The nurse-client

relationship evolves in four phases:

1.O r ientation. During this phase, the client seeks help, and the nurse assists the client to understand
the

problem and the extent of the need for help.

2.Identifi cation. During this phase, the client assumes a posture of dependence, interdependence, or
independence in relation to the nurse (relatedness). The nurse's focus is to assure the person that the
nurse understands the interpersonal meaning of the client's situation.

3.Exploita tion. In this phase, the client derives full value from what the nurse offers through the
relationship. The client uses available services based on self-interest and needs. Power shifts from the
nurse to the client.

4.Res olution. In this final phase, old needs and goals are put aside and new ones adopted. Once older
needs are resolved, newer and more mature ones emerge.

To help clients fulfill their needs, nurses assume many roles: stranger, teacher, resource person,
surrogate, leader, and counselor. Peplau's model continues to be used by clinicians when working with
individuals who have psychologic problems.

Henderson's Definition of Nursing

In 1966, Virginia Henderson's definition of the unique function of nursing was a major stepping stone in
the emergence of nursing as a discipline separate from medicine. Like Nightingale, Henderson describes
nursing in relation to the client and the client's environment. Unlike Nightingale, Henderson sees the
nurse as concerned with both healthy and ill individuals, acknowledges that nurses interact with clients
even when recovery may not be feasible, and mentiones the teaching and advocacy roles of the nurse.

Henderson (1966) conceptualizes the nurse's role as assisting sick or healthy individuals to gain

independence in meeting 14 fundamental needs:

1. Breathing normally
2. Eating and drinking adequately
3. Eliminating body wastes
4. Moving and maintaining a desirable position
5. Sleeping and resting
6. Selecting suitable clothes
7. Maintaining body temperature within normal range by adjusting clothing and modifying the

environment
8. Keeping the body clean and well groomed to protect the integument
9. Avoiding dangers in the environment and avoiding injuring others
10. Communicating with others in expressing emotions, needs, fears, or opinions

11. Worshipping according to one's faith

12. Working in such a way that one feels a sense of accomplishment
13. Playing or participating in various forms of recreation
14. Learning, discovering, or satisfying the curiosity that leads to normal development and health, and

using available health facilities

Henderson has published many works and continues to be cited in current nursing literature. Her
emphasis on the importance of nursing's independence from, and interdependence with, other health
care
disciplines is well recognized.

Rogers's Science of Unitary Human Beings

Martha Rogers first presented her theory of unitary human beings in 1970. It contains complex
conceptualizations related to multiple scientific disciplines (e.g., Einstein's theory of relativity, Burr and
Northrop's electrodynamic theory of life, von Bertalanffy's general systems theory, and many other
disciplines, such as anthropology, psychology, sociology, astronomy, religion, philosophy, history,
biology, and literature).

Rogers views the person as an irreducible whole, the whole being greater than the sum of its parts.

Whole is differentiated from holistic, the latter often used to mean only the sum of all parts. She states

that humans are dynamic energy fields in continuous exchange with environmental fields, both of which
are infinite. The "human field image" perspective surpasses that of the physical body. Both human and
environmental fields are characterized by pattern, a universe of open systems, and four dimensionality.
According to Rogers, unitary man

• Is an irreducible, four-dimensional energy field identified by pattern.

• Manifests characteristics different from the sum of the parts.
• Interacts continuously and creatively with the environment.
• Behaves as a totality.
• As a sentient being, participates creatively in change.

Nurses applying Rogers's theory in practice (a) focus on the person's wholeness, (b) seek to promote
symphonic interaction between the two energy fields (human and environment) to strengthen the
coherence and integrity of the person, (c) coordinate the human field with the rhythmicities of the
environmental field, and (d) direct and redirect patterns of interaction between the two energy fields to
promote maximum health potential.

Nurses' use of noncontact therapeutic touch is based on the concept of human energy fields. The
qualities of the field vary from person to person and are affected by pain and illness. Although the field
is infinite, realistically it is most clearly "felt" within several feet of the body. Nurses trained in
noncontact therapeutic touch claim they can assess and feel the energy field and manipulate it to
enhance the healing process of people who are ill or injured.

Orem's General Theory of Nursing

Dorothea Orem's theory, first published in 1971, includes three related concepts: self-care, self-care
deficit, and nursing systems. Self-care theory is based on four concepts: self-care, self-care agency, self-
care requisites, and therapeutic self-care demand. Self-care refers to those activities an individual
performs independently throughout life to promote and maintain personal well-being. Self-care agency

is the individual's ability to perform self-care activities. It consists of two agents: a self-care agent (an
individual who performs self-care independently) and a dependent care agent (a person other than the
individual who provides the care). Most adults care for themselves, whereas infants and people
weakened by illness or disability require assistance with self-care activities.

Self-care requisites, also called self-care needs, are measures or actions taken to provide self-care. There

are three categories of self-care requisites:

1. Universal requisites are common to all people. They include maintaining intake and elimination of
air, water, and food; balancing rest, solitude, and social interaction; preventing hazards to life and well-
being; and promoting normal human functioning.

2. Developmental requisites result from maturation or are associated with conditions or events, such as

adjusting to a change in body image or to the loss of a spouse.

3. Health deviation requisites result from illness, injury, or disease or its treatment. They include actions
such as seeking health care assistance, carrying out prescribed therapies, and learning to live with the
effects of illness or treatment.

Therapeutic self-care demand refers to all self-care activities required to meet existing self-care

requisites, or in other words, actions to maintain health and well-being (see Figure 3-2).

Self-care deficit results when self-care agency is not adequate to meet the known self-care demand.
Orem's self-care deficit theory explains not only when nursing is needed but also how people can be
assisted through five methods of helping: acting or doing for, guiding, teaching, supporting, and
providing an environment that promotes the individual's abilities to meet current and future demands.

Orem identifies three types of nursing systems:

1. Wholly compensatory systems are required for individuals who are unable to control and monitor

their environment and process information.

2. Partly compensatory systems are designed for individuals who are unable to perform some, but not

all, self-care activities.

3. Supportive-educative (developmental) systems are designed for persons who need to learn to
perform

self-care measures and need assistance to do so.

The five methods of helping discussed for self-care deficit can be used in each nursing system.

King's Goal Attainment Theory

Imogene King's theory of goal attainment (1981) was derived from her conceptual framework (Figure 3-
3). King's framework shows the relationship of operational systems (individuals), interpersonal systems

(groups such as nurse-patient), and social systems (such as educational system, health care system). She
selected 15 concepts from the nursing literature (self, role, perception, communication, interaction,
transaction, growth and development, stress, time, personal space, organization, status, power,
authority,
and decision making) as essential knowledge for use by nurses.

Ten of the concepts in the framework were selected (self, role, perception, communication, interaction,
transaction, growth and development, stress, time, and personal space) as essential knowledge for use
by
nurses in concrete nursing situations. Within this theory, a transaction process model was designed
(Figure 3-4). This process describes the nature of and standard for nurse-patient interactions that lead to
goal attainmentthat nurses purposefully interact and mutually set, explore, and agree to means to
achieve goals. Goal attainment represents outcomes. When this information is recorded in the patient
record, nurses have data that represent evidence-based nursing practice.

King's theory offers insight into nurses' interactions with individuals and groups within the environment.
It highlights the importance of a client's participation in decisions that influence care and focuses on
both the process of nurse-client interaction and the outcomes of care. King believes that her theory,
used
in evidence theory-based practice, blends the art and the science of nursing (2006).

Neuman's Systems Model

Betty Neuman (Neuman& Fawcett, 2002 ), a community health nurse and clinical psychologist,
developed a model based on the individual's relationship to stress, the reaction to it, and reconstitution
factors that are dynamic in nature. Reconstitution is the state of adaptation to stressors.

Neuman views the client as an open system consisting of a basic structure or central core of energy
resources (physiologic, psychologic, sociocultural, developmental, and spiritual) surrounded by two
concentric boundaries or rings referred to as lines of resistance (see Figure 3-5). The lines of resistance
represent internal factors that help the client defend against a stressor; one example is an increase in
the
body's leukocyte count to combat an infection. Outside the lines of resistance are two lines of defense.
The inner or normal line of defense, depicted as a solid line, represents the person's state of equilibrium
or the state of adaptation developed and maintained over time and considered normal for that person.
The flexible line of defense, depicted as a broken line, is dynamic and can be rapidly altered over a short
period of time. It is a protective buffer that prevents stressors from penetrating the normal line of
defense. Certain variables (e.g., sleep deprivation) can create rapid changes in the flexible line of
defense.

Neuman categorizes stressors as intrapersonal stressors, those that occur within the individual (e.g., an
infection); interpersonal stressors, those that occur between individuals (e.g., unrealistic role
expectations); and extrapersonal stressors, those that occur outside the person (e.g., financial
concerns).
The individual's reaction to stressors depends on the strength of the lines of defense. When the lines of
defense fail, the resulting reaction depends on the strength of the lines of resistance. As part of the
reaction, a person's system can adapt to a stressor, an effect known as reconstitution. Nursing
interventions focus on retaining or maintaining system stability. These interventions are carried out on

three preventive levels: primary, secondary, and tertiary.

. Primary prevention focuses on protecting the normal line of defense and strengthening the flexible

line of defense.

2. Secondary prevention focuses on strengthening internal lines of resistance, reducing the reaction, and

increasing resistance factors.

3. Tertiary prevention focuses on readaptation and stability and protects reconstitution or return to

wellness following treatment.

Betty Neuman's model of nursing is applicable to a variety of nursing practice settings involving
individuals, families, groups, and communities. The model is used in many countries and to direct
nursing administration and research programs.

Roy's Adaptation Model

Sister Callista Roy (1997) defines adaptation as "the process and outcome whereby the thinking and
feeling person uses conscious awareness and choice to create human and environmental integration" (p.
44). Roy's work focuses on the increasing complexity of person and environment self-organization, and
on the relationship between and among persons, universe, and what can be considered a supreme
being
or God. Her philosophical assumptions have been refined using major characteristics of "creation
spirituality"a view that "persons and the earth are one, and that they are in God and of God" (p. 46)

Roy focuses on the individual as a biopsychosocial adaptive system that employs a feedback cycle of
input (stimuli), throughput (control processes), and output (behaviors or adaptive responses). Both the
individual and the environment are sources of stimuli that require modification to promote adaptation,
an ongoing purposive response. Adaptive responses contribute to health, which she defines as the
process of being and becoming integrated; ineffective or maladaptive responses do not contribute to
health. Each person's adaptation level is unique and constantly changing.

The goal of Callista Roy's model is to enhance life processes through adaptation in four adaptive modes.

Individuals respond to needs (stimuli) in one of the four modes:

1. The physiologic mode involves the body's basic physiologic needs and ways of adapting with regard to
fluid and electrolytes, activity and rest, circulation and oxygen, nutrition and elimination, protection, the
senses, and neurologic and endocrine function.

2. The self-concept mode includes two components: the physical self, which involves sensation and

body image, and the personal self, which involves self-ideal, self-consistency, and the moral-ethical self.

3. The role function mode is determined by the need for social integrity and refers to the performance
of

duties based on given positions within society.

4. The interdependence mode involves one's relations with significant others and support systems that

provide help, affection, and attention.

In evolving her work since the early 1980s, Roy has expanded the model for application with families
and clients in relationships. She developed the assumption she namedver itiv ity, which refers to
purposefulness of humans in interactions with others and transcending materialism to support caring
(see, for example, Dobratz, 2004).

Leininger's Cultural Care Diversity and Universality Theory

Madeleine Leininger, a nurse anthropologist, put her views on transcultural nursing in print in the 1970s

and then in 1991 published her book Culture Care Diversity and Universality: A Theory of Nursing.

Leininger states that care is the essence of nursing and the dominant, distinctive, and unifying feature of
nursing. She emphasizes that human caring, although a universal phenomenon, varies among cultures in
its expressions, processes, and patterns; it is largely culturally derived. Leininger produced the Sunrise
model to depict her theory of cultural care diversity and universality. This model emphasizes that health
and care are influenced by elements of the social structure, such as technology, religious and
philosophical factors, kinship and social systems, cultural values, political and legal factors, economic
factors, and educational factors. These social factors are addressed within environmental contexts,
language expressions, and ethnohistory. Each of these systems is part of the social structure of any
society; health care expressions, patterns, and practices are also integral parts of these aspects of social
structure (Leininger& McFarland, 2002). In order for nurses to assist people of diverse cultures,
Leininger presents three intervention modes:

• Culture care preservation and maintenance

• Culture care accommodation, negotiation, or both
• Culture care restructuring and repatterning
Leininger states that her theory is the only one that "searches for comprehensive and holistic care data
relying on social structure, worldview, and multiple factors in a culture in order to get a holistic
knowledge base about care" (Leininger, 2006, p. 319).

Watson's Human Caring Theory

Jean Watson (2005) believes the practice of caring is central to nursing; it is the unifying focus for
practice. Her major assumptions about caring are shown in Box 3-1. Nursing interventions related to
human care originally referred to as carative factors have now been translated into clinical caritas
processes (Watson, 2006):

BOX 3-1 Watson's Assumptions of Caring

• Human caring in nursing is not just an emotion, concern, attitude, or benevolent desire. Caring
connotes a personal response.

• Caring is an intersubjective human process and is the moral ideal of nursing.

• Caring can be effectively demonstrated only interpersonally.

• Effective caring promotes health and individual or family growth.

• Caring promotes health more than does curing.

• Caring responses accept a person not only as they are now, but also for what the person may become.

• A caring environment offers the development of potential while allowing the person to choose the best

action for the self at a given point in time

Caring occasions involve action and choice by nurse and client. If the caring occasion is transpersonal,
the limits of openness expand, as do human capacities.

• The most abstract characteristic of a caring person is that the person is somehow responsive to
another

person as a unique individual, perceives the other's feelings, and sets one person apart from another.

• Human caring involves values, a will and a commitment to care, knowledge, caring actions, and

consequences.

• The ideal and value of caring is a starting point, a stance, and an attitude that has to become a will, an

intention, a commitment, and a conscious judgment that manifests itself in concrete acts.

Note: From J. Watson, personal communication, September 22, 2002. Also see her website:

http://www2.uchsc.edu/son/caring/content/default.asp

1. Formation of humanistic-altruistic system of values, becomes: "practice of loving-kindness and

equanimity within context of caring consciousness."

2. Instillation of faith-hope, becomes: "being authentically present, and enabling and sustaining the
deep

belief system and subjective life world of self and one-being-cared-for."

3. Cultivation of sensitivity to one's self and to others, becomes: "cultivation of one's own spiritual

practices and transpersonal self, going beyond ego self."

4. Development of a helping-trusting, human caring relationship, becomes: "developing and sustaining a

helping-trusting, authentic caring relationship."

5. Promotion and acceptance of the expression of positive and negative feelings, becomes: "being
present to, and supportive of the expression of positive and negative feelings as a connection with
deeper spirit of self and the one-being-cared-for."

6. Systematic use of a creative problem-solving caring process, becomes: "creative use of self and all

ways of knowing as part of the caring process; to engage in artistry of caring-healing practices."

7. Promotion of transpersonal teaching-learning, becomes: "engaging in genuine teaching-learning

experience that attends to unity of being and meaning attempting to stay within other's frame of
reference."
8. Provision for a supportive, protective, and/or corrective mental, physical, societal, and spiritual
environment, becomes: "creating healing environment at all levels (physical as well as non-physical),
subtle environment of energy and consciousness, whereby wholeness, beauty, comfort, dignity, and
peace are potentiated."

9. Assistance with gratification of human needs, becomes: "assisting with basic needs, with an
intentional caring consciousness, administering 'human care essentials,' which potentiate alignment of
mindbodyspirit, wholeness, and unity of being in all aspects of care," tending to both embodied spirit
and evolving spiritual emergence.

10. Allowance for existential-phenomenological-spiritual forces, becomes: "opening and attending to

spiritual-mysterious, and existential dimensions of one's own life-death; soul care for self and the one-
being-cared-for."

Watson's theory of human caring has received worldwide recognition and is a major force in redefining
nursing as a caring-healing health model. Watson has also explored how her theory and that of Rogers
can be integrated and synthesized to form a Unitary Caring Science (Watson& Smith, 2002 ).

Parse's Human Becoming Theory

Parse (1999) proposes three assumptions about human becoming:

1. Human becoming is freely choosing personal meaning in situations in the intersubjective process of

relating value priorities.

2. Human becoming is cocreating rhythmic patterns or relating in mutual process with the universe.
3. Human becoming is cotranscending multidimensionally with the emerging possibles (p. 6).
These three assumptions focus on meaning, rhythmicity, and cotranscendence.
1. Meaning arises from a person's interrelationship with the world and refers to happenings to which
the

person attaches varying degrees of significance.

2. Rhythmicity is the movement toward greater diversity.
3. Cotranscendence is the process of reaching out beyond the self.
Parse's model of human becoming emphasizes how individuals choose and bear responsibility for

patterns of personal health. Parse contends that the client, not the nurse, is the authority figure and
decision maker. The nurse's role involves helping individuals and families in choosing the possibilities
for changing the health process. Specifically, the nurse's role consists of